Kazem A, Al-Darzi W, Mohammed M, Lemor A, Lee J, Wang D, Basir M, Alaswad K, O'Neill B, Frisoli T, Eng M, O'Neill W, and Villablanca P. Safety, feasibility, and outcomes of transcaval access for the delivery of Impella microaxial-flow pump 5.0 in patients with acute heart failure. Eur J Heart Fail 2021; 23(SUPPL 2):206.
Eur J Heart Fail
Background: Transcaval access (TCA) may enable fully percutaneous mechanical circulatory support (MCS) without the hazards of vascular complication in patients with heart failure that require left ventricular unloading.
Purpose: To review the safety, feasibility, and outcomes of using TCA to deliver Impella 5.0 MCS in patients with ischemic and non-ischemic systolic acute heart failure. Methods: This single center retrospective study included all patients that underwent TCA placement of a 5.0 Impella from June 2015 to January 2021. Demographic, clinical and procedural variables, and in-hospital outcomes were collected. The procedure was performed by electrifying a caval guidewire and advancing it into a pre-positioned aortic snare. After exchanging for a rigid guidewire, a 22 or 24Fr sheath was delivered into the aorta and then the Impella 5.0 was placed in the left ventricle through TCA sheaths.
Results: A total of 43 patients were included in the analysis. The average age was 56.9 years (interquartile range [IQR], 52-65.5), of which, 70%(n=30) were males. Fifteen patients had non-ischemic cardiomyopathy and 28 had ischemic cardiomyopathy. Baseline average left ventricular ejection fraction prior to implantation was 23.6% (IQR, 13.75-29.75). 86% of the patients were in category C-D of the SCAI classification schema for cardiogenic shock (CS), 39.5% required inotropes and 48.8% required pressors prior to the procedure; 54% had a prior MCS in place. Only 18.6% of the cases had prior CT imaging reviewed for planning. TCA was successful in all attempted patients and the MCS delivery was achieved in 100% of the cohort. The available hemodynamic parameters prior and after Impella 5.0 implantation via Table 1 TCA are summarized in table 1. From the total cohort, only 29 patients survived to explant device and TCA sheath. The explant was successful in all patients using nitinol occluders; two patients required a covered stent at the arteriotomy site due to right sided heart failure from residual fistula; no surgical repair was necessary. All residual fistulous tracks were graded as1 from Impella insertion/removal site was observed in 9.3%,which didn't require further intervention. No vascular complication of the access site was observed with TCA. During hospitalization, 20.9% had VT/VF and 4.7% a PEA after implantation (all CS patients). 13.9% of the patients had AKI requiring hemodialysis and no stroke was observed in the entire group. The average length of stay for entire cohort was 16.3 days (IQR, 3.25-18.75).
Conclusions: Transcaval access of 5.0 Impella is safe and feasible under expert hands for patients where more conventional MCS devices do not provide enough support or have inadequate peripheral arterial access.